YOUTH CONSULTATION SERVICE
INDIVIDUAL SERVICE PLAN
Place program stamp here
Client’s Name: Jane Consumer CMHC #: 12345
DOB: 9/14/00 DOA: 5/30/12 Review Date: 9/6/13
ADD (anticipated discharge date): 10/2013-This has been changed from 9/2013 because the RTC program that Jane was accepted into does not have an open bed as of yet.
Date Submitted to DYFS and or other significant linkage: 9/20/13
Presenting problem:
____10 DAY
_X__MONTHLY
____QUARTERLY
____ANNUAL
____DISCHARGE
DSM-IV Diagnosis
Axis I: 309.81 Post Traumatic Stress Disorder, chronic, complex
300.00 Anxiety Disorder Not Otherwise Specified
296.90 Mood Disorder Not Otherwise Specified
311 Depressive Disorder Not Otherwise Specified (Pre Menstrual Dysphoric Disorder)
314.01 Attention Deficit Hyperactivity Disorder, Combined Type
313.81 Oppositional Defiant Disorder
Axis II: V71.09 No diagnosis on Axis II
Axis III: Myopia
Axis IV: Problems with primary support-trauma by being abandoned by father, severe conflict with and aggression towards mother and brother, Educational problems-currently expelled from alternative school, classified Emotionally Disturbed, discord with peers and teachers, Problems related to the social environment-frequent peer conflicts, and currently in out of home placement with a history of being in 2 other out of home placements
Axis V: 55
Client’s strengths: Jane is smart, engaging, outgoing, friendly, and athletic.
Client’s needs: Jane needs to start processing her past history of loss and abandonment as a way to better regulate her emotions. Jane needs to learn and utilize positive coping skills to help her to deal with difficult feelings of depression and anger. Jane needs to decrease her instances of verbal and physical aggression towards others.
Integrated Treatment Summary (including medication updates): This is Jane’s 17th monthly treatment team meeting. A few weeks ago Jane completed her ESY program at Dublin School. Her social worker reported that during this program Jane often put herself in situations that did not pertain to her and that she had trouble staying focused and on task. Jane received A’s, B’s, and mostly C’s for her classes in that program. This week she started attending 8th grade at Dublin. Jane’s teacher and social worker reported this week that Jane has been doing well behaviorally in school so far. They reported that she has been arguing with a few of her male peers but that she has not been letting it get escalated. Jane speaks to her mother on the phone weekly. Jane’s mother reports that overall Jane has been respectful to her on the phone. Jane has also been speaking to her half-sister on the phone and that makes Jane very happy. Jane is appropriate during these conversations. Jane went out with her mother and her UCM worker after the last treatment team meeting for a day pass. Jane became angry at them during this day pass when they were discussing some of her negative behaviors. Jane reacted to them in a disrespectful manner as a result. Jane has been continuing to email her father and these emails have been somewhat inappropriate. Jane recently emailed her resident peers and some of her siblings the emails that she has between her and her father. As a result one of Jane’s resident peers emailed Jane’s father to yell at him for Jane. Jane is now only allowed to use her email with her mother. In the beginning of this treatment cycle Jane was disrespectful to this clinician a couple of times after this clinician redirected her. Staff report that Jane has been significantly less disrespectful and defiant towards them during this treatment cycle. Jane was not physical controlled during this treatment cycle. At times Jane is disrespectful to her peers. However, recently a new peer threatened Jane and she responded very appropriately to this. In therapy Jane has been working on learning DBT skills, on discussing her father, and on learning how to appropriately deal with her peer issues in school. The RTC program that Jane was accepted into still does not have an open bed for her. They project to have an opening for Jane sometime this month. Due to Jane’s progress she moved up to Senior Level.
Medications: Seroquel XR 250mg at 4pm, Clonidine 0.05mg at 8am, Clonidine 0.1mg at 1pm, Clonidine 0.15mg at 8pm, Lexapro 15mg at 8am (Jane’s Lexapro goes up to 20mg at 8am during her menstrual cycle).
Visitation Plan: Jane is allowed to have visits with her mother, her grandparents, and her brother. Jane is allowed to have overnight and weekend visits with her mother, as she is on Senior Level.
Client’s Name: Jane Consumer CMHC #: 12345
DOB: 9/14/00 DOA: 5/30/12 Review Date: 9/6/13
Problem Area (Updated on 3/1/13): Jane has experienced loss and abandonment from her biological father. He and her mother separated when Jane was 4 years old. For the first few years after this separation Jane’s father was in and out of Jane’s life. For the past couple of years he has not been in contact with Jane at all. As a result, Jane has a difficult time regulating her emotions and she has low self-esteem. She needs to process this loss and abandonment in order to better regulate her emotions and to understand the current impact that these experiences have on her.
Strength: Jane is very engaging.
Domain: Emotional
Goal: Jane will better regulate her emotions and she will understand how her father’s absence has impacted her by processing her issues of loss and abandonment.
Objective 1: Jane will identify and reframe at least 5 of her self-disparaging statements.
Technique/ Interventions:
· Clinician will meet with Jane once a week for individual counseling and once a week for group counseling to help her to identify the negative self-statements that she has about herself. Clinician will help Jane to confront and reframe these self-disparaging statements.
Objective Initiate on: 3/1/13
Anticipated Time Frame: 7 months-This has been extended from 5 months because it has not been achieved yet.
Objective Completed: (Yes) Date: (No)___X___
Objective 2: Jane will appropriately regulate her overwhelming emotions as evidenced by Jane using her DBT skills at least 3 times per week.
Objective Initiate on: 4/19/13
Anticipated Time Frame: 6 months-This has been extended from 5 months because it has not been achieved yet.
Objective Completed: (Yes) Date: (No)___X___
Technique/ Interventions:
· Clinician will meet with Jane once a week for individual counseling to teach Jane various DBT skills that she can use when she starts to experience a difficult feeling.
· RA staff will remind Jane to use these skills once she starts to become upset.
· Updated on 5/17/13-Jane will complete a DBT Diary Card daily to assess her feelings for the day and to assess which DBT skills she used that day.
Criteria and Documentation:
· Progress notes, therapy worksheets, treatment team meetings monthly, DBT Diary Card
Persons Responsible:
· Jane, Clinician, Jane’s mother, RA staff
Progress:
1. During the last month, Jane has been able to identify and reframe 3 of her self-disparaging statements.
2. Jane has been using her DBT skills about twice per week.
Created 2013 P:\Research\PIA\CRM\10.1.3.1 p.1
YOUTH CONSULTATION SERVICE
INDIVIDUAL SERVICE PLAN
Place program stamp here
Client’s Name: Jane Consumer CMHC #: 12345
DOB: 9/14/00 DOA: 5/30/12 Review Date: 9/6/13
Problem Area: Jane has an extensive history of exhibiting verbal and physical aggression towards others and of exhibiting defiant and disrespectful behaviors towards others. Specifically, Jane has a history of hurting and injuring her mother and her brother. Jane also has a history of being physically aggressive towards teachers and peers.
Strength: Jane is aware that her negative behavioral choices are inappropriate and harmful.
Domain: Behavioral
Goal: Jane will utilize positive coping skills when she is experiencing difficult feelings instead of exhibiting physical and verbal aggression towards others.
Objective 1: Jane will have no more than 1 physical control each month.
Objectives Initiate on: 8/14/12
Anticipated Time Frame: 14 months-This Objective has been extended from 13 months because it has not been achieved yet.
Objective Completed: (Yes) Date: (No)__X____
Technique/ Interventions:
· Jane will attend the anger management psycho-educational group once a week to help her learn positive techniques to better manage her anger.
· Clinician will meet with Jane once a week for individual counseling to help her to increase her coping skills.
· Staff will physically control Jane if she becomes physically aggressive towards peers or staff.
· Jane will take the following medications: Seroquel XR 250mg at 4pm, Clonidine 0.05mg at 8am, Clonidine 0.1mg at 1pm, Clonidine 0.15mg at 8pm, Lexapro 15mg at 8am (Jane’s Lexapro goes up to 20mg at 8am during her menstrual cycle).
Objective 2: Jane will have no more than 1 instance of lying to staff each day.
Objectives Initiate on: 1/4/13
Anticipated Time Frame: 9 months-This Objective has been extended from 9 months because it has not been achieved yet.
Objective Completed: (Yes) Date: (No)__X____
Technique/ Interventions:
· Clinician will meet with Jane once a week for individual counseling and once a week for group counseling to help her to understand the risks and consequences to lying.
· Staff will inform Clinician via a data tracking sheet when Jane lies to them.
· Jane will take the following medications: Seroquel 250mg at 4pm, Clonidine 0.05mg at 8am, Clonidine 0.1mg at 1pm, Clonidine 0.15mg at 8pm, Lexapro 15mg at 8am (Jane’s Lexapro goes up to 20mg at 8am during her menstrual cycle).
Objective 3: Jane will have no more than 1 instance of being disrespectful to staff each day.
Objectives Initiate on: 2/1/13
Anticipated Time Frame: 8 months-This has been extended from 7 months because Jane has not achieved it yet.
Objective Completed: (Yes) Date: (No)__X____
Technique/ Interventions:
· Clinician will meet with Jane once a week for individual counseling to help her learn how to express her feelings to others in an appropriate manner. Clinician will also help Jane
to understand how her tone and the words that she uses can be perceived as disrespectful.
· Staff will encourage Jane to use her coping skills when she becomes upset or angry.
· Jane will take the following medications: Seroquel 250mg at 4pm, Clonidine 0.05mg at 8am, Clonidine 0.1mg at 1pm, Clonidine 0.15mg at 8pm, Lexapro 15mg at 8am (Jane’s Lexapro goes up to 20mg at 8am during her menstrual cycle).
Criteria and Documentation:
· Progress notes, psycho educational group notes, behavior tracking sheets, RA feedback forms, treatment team meetings monthly, physical control reports, incident reports
Persons Responsible:
· Jane, Clinician, RA staff
Progress:
1. Jane was not physically controlled during this treatment cycle. This Objective will continue to be monitored.
2. During the last month, Jane has lied to staff 1-2 times per day.
3. In the beginning of this treatment cycle Jane was disrespectful to this clinician 3 times after this clinician redirected her. Staff report that Jane has been significantly less disrespectful and defiant towards them during this treatment cycle. Jane is disrespectful to staff 1-2 times per day.
Client’s Name: Jane Consumer CMHC #: 12345
DOB: 9/14/00 DOA: 5/30/12 Review Date: 9/6/13
Problem Area: This is Jane’s third residential placement in the past few years so she has had a difficult time making meaningful friendships with peers. Jane is able to make friends but she has a difficult time sustaining them because she often becomes controlling and aggressive with them.
Strength: Jane has been able to make friends in the past.
Domain: Social
Goal: “I need to be able to keep friends for long periods of time” (Goal in Jane’s words).
Objective 1: Jane will earn 80 points a week for maintaining positive peer relations on her behavioral modification point’s sheet.
Objective Initiate on: 11/16/12
Anticipated Time Frame: 11 months-This Objective has been extended from 10 months because it has not been achieved it yet.
Objective Completed: (Yes) Date: (No)__X____
Technique/ Intervention:
· Clinician will provide group therapy once a week and individual therapy once a week to help teach Jane pro social skills.
· Jane will attend Social Skills psycho-education groups weekly.
· Jane will take the following medications: Seroquel XR 250mg at 4pm, Clonidine 0.1mg at 1pm, Clonidine 0.15mg at 8pm, Lexapro 15mg at 8am (Jane’s Lexapro goes up to 20mg at 8am during her menstrual cycle).
Objective 2: Jane will have no more than two instances of physically and or/verbally aggressive behaviors towards her peers each week.
Objective Initiate on: 1/4/13
Anticipated Time Frame: 9 months-This Objective has been extended from 7 months because it has not been achieved it yet.
Objective Completed: (Yes) Date: (No)__X____
Technique/ Intervention:
· Clinician will provide group therapy once a week and individual therapy once a week to help teach Jane pro social skills, conflict resolution skills, and anger management skills.
· Jane will attend the Social Skills and Anger Management psycho-education groups weekly.
· Staff will encourage Jane to use her coping skills when she starts to become angry at her peers.
· Jane will take the following medications: Seroquel XR 250mg at 4pm, Clonidine 0.1mg at 1pm, Clonidine 0.15mg at 8pm, Lexapro 15mg at 8am (Jane’s Lexapro goes up to 20mg at 8am during her menstrual cycle).
Criteria and Documentation:
· Progress notes, behavior tracking sheets, RA feedback forms.
Persons Responsible:
· Jane, Clinician, RA staff
Progress:
1. From 8/9-8/15 Jane earned 80 points. From 8/16-8/22 Jane earned 76 points. From 8/23-8/29 Jane earned 84 points. From 8/30-9/5 Jane earned 84 points.
2. Overall Jane has been verbally aggressive towards her resident peers 1-2 times per week. At times Jane is disrespectful to her peers. However, recently a new peer threatened Jane and she responded very appropriately to this. This objective will continue until Jane consistently achieves 0-1 instance of verbal aggression per week at which point the objective will change to 0 incidents of verbal aggression.
Client’s Name: Jane Consumer CMHC #: 12345
DOB: 9/14/00 DOA: 5/30/12 Review Date: 9/6/13
Problem Area: Jane does not have a relationship with her biological father, as he has been in and out of her life since the age of 4. Jane does not understand why her father is not in her life. Jane lives with her mother and her brother, and she has a history of exhibiting verbal and physical aggression towards them when she is mad. Jane does not open up to her mother about her feelings when she is upset, angry, or sad. Jane’s mother would like to learn positive parenting skills in order to effectively manage Jane’s behaviors in the home.